Thursday, March 07, 2013


When is enough enough?

This past week, most of the various national news media carried the story of an 87 year old woman in an independent living facility in California.  She collapsed during lunch, and--in keeping with the policy in place at the facility--staff called 911 for an emergency medical transport to come.  The 911 operator asked about the woman's immediate state--was she breathing?  And when the staff person said that the woman was breathing only faintly, the 911 operator sternly instructed the staff person--you have to start CPR right now.

When the staff person, identified as a nurse, demurred, the 911 operator became very insistent and said--she might die.  And, therewith, the focus of the story became clear.  The only fault seemed to be the refusal of the nurse to begin CPR.

But there are other questions that should have been asked.  Did the 87 year old woman have an advance directive?  Did she want CPR to be given in the event that she suffered cardiac arrest or some other catastrophic health event? What did her family want for her treatment? How effective is CPR?  What were her chances of survival even with CPR?  Perhaps predictably, none of those questions was asked--the initial news coverage seemingly tripped over itself trying to make the story as negative and sensational as possible.  I must, however, give credit to NBC which did begin to raise the questions.

We have been so accustomed to seeing CPR performed as part of a dramatic scene in a television drama that we most likely assume it always works.  But does it?  The short answer is no. 

One website indicates that CPR is rarely effective:
  • 2% to 30% effectiveness when administered outside of the hospital
  • 6% to 15% for hospitalized patients
  • Less than 5% for elderly victims with multiple medical problems

Recently, my husband and I updated our wills, which--this time--included advance directives.  We want our preferences to be known to family and health professionals.  There comes a time when enough is enough.

This is not an easy subject to broach.  And the question goes beyond end of life care--it should even be raised in smaller ways.  Part of the reason that Medicare consumes the amount of money it does is because so many procedures are paid for.  True, they are paid for at Medicare's rate--but, to my knowledge, there is no information for patients that says "you don't  have to have every procedure a doctor recommends." 

I am currently helping my elderly father (93) and my step-mother (80) make various decisions.  I am struck by the number of times that a medical provider simply schedules the next appointment for 6 months.  True, these appointments are well-care appointments, and--generally--that is the best approach to medicine.  But when I picked my step-mother up from her recent dermatology appointment, the nurse scheduled her for a 6-month checkup.  So I pushed back a bit--why 6 months?  The nurse said--well, there' s a history of skin cancer.  So I asked my step-mother--how long ago?  She couldn't quite recall, but said nothing recently.  I have had multiple basal cell skin cancers--and I go for checkups once a year.

I suggested to my father and step-mother that they can decline to schedule appointments if they feel they are unnecessary.  To my thinking, this is especially true for simple skin care--skin cancers (other than melanoma) takes YEARS, even decades, to develop.  And is that a serious concern for someone in his or her 80s or 90s?  Please understand, I also ask myself the question--at my age. 

So, it all comes back to the question of when is enough enough?  I think part of American obsession with youth, with seeming never-ending life, feeds the tendency to think we must always intervene--always give CPR.  But, part of the human bargain is this: we are born AND we die. 

Sometimes enough is enough.


Tossing Pebbles in the Stream said...

I found the nurses refusal to do CPR callous. She gave up the right to just watch nature takes it's course when she called 911. When you do so you are saying intervention is needed. Or was she just covering her ass and that of the institution.

I have since read that the family is content with the decision and outcome as the woman has at least spoken of not wanting intervention.
If the nurse new this she should have told the 911 operator this or better still not wasted the time and effort of 911 responders.

possumlady said...

I felt the same way as Tossing Pebbles. If the nurse did not know of the DNR directive, then, yes she was very callous. BUT, if she knew of it, then WHY didn't she tell the 911 operator? Even if she didn't know, maybe she knew the myriad of health problems of the woman and could have relayed that to the operator. If anything, it would have saved the operator the anguish of feeling helpless.

Just the nurse's tone seemed very nonchalant. But again, we don't know what all was going on at the time.

Peruby said...

Blame it on the HIPAA privacy rule! The nurse was probably afraid to say anything.

Ginnie said...

I agree with the HIPPA comment. I still work in the medical field & the nurses are damned if they do and damned if they don't.

Anvilcloud said...

I just read a piece of fiction based on looking for something resembling eternal life here on earth.

Jayne said...

For me, as a nurse for going on 29 years, it all boils down to quality vs quantity of life. CPR on ANY 87 year old person is not going to have a good outcome. If she miraculously DID survive, chances are her remaining years would be spent bed bound in a nursing home, maybe conscious of what was going on around her, maybe not. Is that any way to live? Not for me.

It truly IS imperative that we all execute advance directives so that our wishes are known. If I live to the ripe old age of 87 and I fall over dead in my lunch salad, so be it. I'd have lived a good long life and one of independence, which matters more to me than just my heart beating. I only pray that I do simply go in my sleep so that there won't be any chance of someone trying to resuscitate my 87 year old body.

Leslie Patterson said...

You and I are in tune! I would actually encourage people far younger than the woman in question to have advance directives. My mother died at 66 of melanoma. She had an advance directive in place by the time she was 60 because she had been horrified by the Terry Schiavo case. She also had made it clear that she wished to die at home. Her willingness to have frank discussions about death meant that she had a far better death than most people and that my father and I were able to know that we had acted according to her wishes.

KGMom said...

Interesting thoughts from you all--I still think the news reported the story in such a way that the real questions weren't asked. Was the nurse negligent? cavalier? I see that the local authorities have declined to bring any charges. The family is satisfied.
Of course, if the elderly woman had an advance directive, that should be known--but I am not sure how a facility might be able to pull out that fact to someone who is at lunch. I have gone to where my parents now live and been in their dining room. I would not be at all surprised if their facility had a blanket policy that covers all--whether or no someone has an advance directive.
And, yes, Leslie is ABSOLUTELY correct--everyone EVERYONE should sit down right now and write out his/her preference for medical intervention and extraordinary measures. If you want that--then say so. If you don't--then say so.

NCmountainwoman said...

I know that many independent living residences for seniors DO NOT initiate CPR but call 911. And in all cases, the residents are fully informed of this when they apply. This was not a nursing home, not a rehab, nor even an assisted living residence.

What this nurse might have done had this occurred on the street is one thing. What she was obliged to do (or not do in this instance) under the policies of her employment is quite another. Her actions were proper and I am sorry she is being considered callous for doing her job.

KGMom said...

MC MntWmn--I agree with your assessment. That was my sense, too. Residents would know what the policies are, and the nurse (so described) did what her employer required.

troutbirder said...

Mmmm I have an advanced directive. A most interesting post. I tend to agree with Jayne and NCW. With the exception of PBS Tv is a joke when it comes to getting the whole story without sensationalism...;(

Anonymous said...

My husband and I updated our wills and end of life directives this summer. the attorney made copies of the directives to send to each of our children now so there will be no misunderstanding or arguments.

I hope they don't have to be pulled out for a long, long time, but there is some piece of mind in knowing we've done it.